Healthcare Provider Details

I. General information

NPI: 1144459801
Provider Name (Legal Business Name): FRED ELMER MCKINLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2009
Last Update Date: 07/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 MCLAUGHLIN CIR
CHELSEA ME
04330-1084
US

IV. Provider business mailing address

75 MCLAUGHLIN CIR
CHELSEA ME
04330-1084
US

V. Phone/Fax

Practice location:
  • Phone: 207-313-9212
  • Fax:
Mailing address:
  • Phone: 207-313-9212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: